Oesophageal Disorders - JU Medicine€¦ · Patho-Physiology Percent of time oesophageal Ph

Oesophageal Disorders

Anatomy

Upper sphincter

Lower sphincter

Gastric Cardia

Oesophageal body

Diaphragm

Symptoms Of Oesophageal

Disorders

Dysphagia

Odynophagia

Heartburn

Atypical Chest Pain

Regurgitation

Diagnostic Tools

Barium Swallow

Endoscopy

Motility Studies

Oesophageal pH monitoring

Impedance

Barium Swallow

Endoscopy

24 hrs oesophageal

pH monitoring

pH probe

Sensor

Lower Oesophageal sphincter

Achalasia

There is failure of relaxation of the lower

oesophageal sphincter.

There is non peristaltic contractions in

the body of the oesophagus.

There is loss of intramural inhibitory

neurons (VIP, Nitric oxide)

Achalasia

Psuedoachalaisa or secondary causes of

achalasia include:

Gastric carcinoma

lymphoma

chagas disease

eosinophilic gastroenteritis

neurodegenarative disorders.

Clinical Features

Dysphagia.

Chest pain.

Regurgitation.

Difficulty in belching.

Diagnosis

Symptoms and signs.

CXR: absence of gastric bubble.

Air fluid level.

tubular mass in the mediastenum.

Barium swallow:

Dilatation.

Beak-like narrowing in the lower end.

Abnormal peristalsis.

Barium Swallow

Diagnosis

Manometry:

Normal or elevated LOS pressure.

Failure of relaxation of the LOS

during swallowing.

Elevated pressure in the body of

oesophagus.

Waves are non peristaltic.

Endoscopy

Dilated lumen contains food and fluids

Narrow sphincter with resistance to the

passage of the endoscope.

Important to exclude secondary causes.

Treatment

Soft food, sedatives and and

anticholenergic drugs.

Nitrate and calcium channel blockers.

Botulinum toxins injection.

Balloon dilatation.

Hellers extra mucosal myotomy.

Hypertensive LES

Increase resting pressure >40 mmHg of

LES

Normal peristalsis and normal LES

relaxation with wet swallows

Diffuse oesophageal spasm

Simultaneous pressure wave in the

smooth muscle> 30 % swallows

Periods of normal peristalsis

Prolonged duration of some pressure

wave

Nutcracker oesophagus

Mean amplitude peristaltic pressures by

wet swallows >180 mmHg

Other disorders

CERST: atrophy of smooth muscle

Eosinophilic esophagitis: Rx with steroids

inhaler (swallowed)

Gastro-oesophageal Reflux

disease

The flow back of the gastric content to the

oesophagus at a rate more than the

physiological one .

High prevalence in the general population.

There is failure of anti-reflux mechanism.

Anti Reflux Mechanism

The gradient pressure between the

stomach and oesophagus is lost

Causes OF Reflux

Decrease in LOS tone, and or peristalsis:

Muscle weakness.

Scleroderma.

Pregnancy.

Smoking.

Anticholenergics

Nitrate, aminophylins, B agonists

Surgical cause.

Oesophagitis

Causes OF Reflux

Increased Gastric Volume.

Stasis

Pyloric stenosis.

Hiatus Hernia.

Increase gastric pressure (preg,Asci)

Incompetence of the crural muscles.

Patho-Physiology

Percent of time oesophageal Ph<4

correlate with degree of damage.

Oesphagitis is the result of persistent

reflux which can be mild to sever

(ulceration).

Fibrosis and stricture can result from

server reflux.

Clinical Features

Asymptomatic.

Regurgitation.

Heart burn.

Chest pain.

Dysphagia

Hoarsens, cough, Aspiration pneumonia,

asthma.

Diagnosis

Barium Swallow.

Endoscopy.

24hrs ph monitoring.

Bernstein test.

Laryngoscopy.

High reselution Manometry & Impedence.

Treatment

Life style adjustment.

H2 receptors blockers

PPI.

Fundoplication.

Barrett’s Oesophagus

As a result of long standing reflux.

There is transformation of normal

squamous to columnar type epithelium in

the lower part of oesophagus.

There is increased risk of adenocarcinoma

which is 30-125 times than the general

population.

1. gastro-esophageal junction

3. Biopsy showing intestinal epithelium

2. Recognize the Metaplastic columnar epithelium

Diagnosis

AGA, Gastroenterology 2011;140:1084

Gastro-Esophageal Junction and Barrett’s Esophagus

Normal Gastro-oesophageal Junction

Abu sneineh et al GUT supp 2004

Prague Classification

C3M6

Abu sneineh et al GUT supp 2004

Treatment

Treat GORD

Surveillance for dysplasia

Endoscopic therapy for dysplasia

Surgery

Corrosive oesophagitis

Caused by ingestion of strong alkali or

acid.

May cause sever ulceration and end up in

fibrosis and stricture formation.

Zinker Diverticula

Occurs in the posterior hypopharyngeal

wall.

Halitosis and food regurgitation

Cricopharyngeal myotomy

Oeophageal Webs

Congenital or inflammatory constrictions

usually in the hypo pharynx .

May cause dysphagia.

May be associated with Iron deffeciency

anemia.

Treatment by dilatation.

Schatzki Ring

Thin constriction at the Squamo-columinar

junction.

Common cause for dysphagia and

underlies food bolus obstruction.

Treated by dilatation.

Hiatus Hernia

Sliding : the gastro-oesophageal junction and part of the fundus lies in the thoracic cavity.

May contribute to GORD

Para-Oesophageal hernia: part of the stomach is herniated beside the G/O junction which is normally located.

May incarcerate ulcerate or cause dysphagia.

Mallory-Weiss Syndrome

Usually preceded by vomiting and

retching.

Tear at the gastro-oesophageal junction.

Patients presents with upper GI bleed

Most cases resolves spontaneously.